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vP!t'fiF, <br /> Y�'F7it• "t€1' ��ItS�N�� .`� ���,�� "�`� ,:i� s��l���,��d8°'. „ '@��• $ir�11Clp Ol <br /> Cai!fpmie Integreled waste AAanagsn»nt Board <br /> ■ CA Uniform Waste and Used Tire Manifest PO Box 1259, Sacramento.CA 9U112-1259 <br /> ��` E X A M P L E 1 2 3 Manifest Number <br /> INSTRUCTIONS ON BACK M (7 - 1 2 7 6 9 4 <br /> PAHA 1 �'�t fl£ LCtItIIt LUTED E7<Y T �'1}tiMltJfBR foleasie prim) <br /> i❑Pick Up 1 <br /> ❑Import from <br /> (It outside Gelligrnia Stlitercountry) \` 1�jr, <br /> ❑ Delivery <br /> C3 Export to <br /> (If ptlt8ida;(,ta'IRim Stip DWDtry) Hauler'6 Business Phone <br /> • (Include area Dods) ( ) �� ( <br /> Hauler Exemption (11 applicable) <br /> © ❑Govemmertt LEA Exempt <br /> Load Date(MMlDDlYY) Log Number ❑Agriculture ❑Common Carried <br /> ` Back Haul <br /> O Indicate(It applicable)C1In Transit <br /> License Plate Number state Decal Number <br /> DConfldentiality Claim:The information provided In Pan I and Pan II of Me form should be considered confidil lel,proprietary,andmr trade secret. Ir <br /> accordance wlth Title 14,CCP.,Section 17041 et.aeq,should any member of the publlo request dlseloeure of this information,I request that CIWMB contact <br /> me at the address and telephone number above. <br /> I Carti'y that under penalty of pal under the laws of the 518W of Callforrla that the Inlor-nation provided above Is due and correct. In additlon,I em aware that Ilial+damn of this <br /> Informalion may r6sul;In suspenslen,revocall or dtnlai of rsrewel of the Waste Tire Hauler Registil pursuant to Public Resources Coda aeetion 42M and may rseuit.n civil <br /> panalil up to 526,000 per day,per vlo:e!lon or acminlatretwe penalties up to 55,000 per vioiaton per day ee described In Public Reaources Code seotron 42802. <br /> L, I <br /> Driver's Naline(print drive s Signature-ASO Da e <br /> FAC LIITY.(please print),a OOMPIC TE AC UAL-Ll-01il 1 �T`HE 'f AigE PICKIED-UP OR AF4".�. "�. <br /> PART :Vk9TE'TIflE=1�5F1" Il' IU 1�1DrUSE <br /> Business Name Facility's Business Phone(Include area code) <br /> �0 �e -mac-a,,,�., a� <br /> Number&Street Address <br /> 1 ❑Address Saint As Hauler <br /> Change Cf Address <br /> y \ she ` zip code <br /> Tire Types and Amount$ intended Use <br /> ❑ PeesEnper ❑Oversize read,Fleuse <br /> Tire Program ID Site Suffix <br /> Recycle <br /> i <br /> LO ypa(cheek dory one ruok ❑Other <br /> ole Tire Count LJ W. hon Po6fil ❑Fuel <br /> tll�, <br /> �]VotuMa:Cublc.Yards' 1Ntirlghtlnisdea r 01sposaVLandfill <br /> Load Amount Comment Area <br /> ❑Confidentlality Claim:The Informailor provided In Part I and Part 11 of this form should be Considered oonfldentlal,proprietary,and/or trade secret. <br /> in accordance w th T tie 14,CCR,Section 17041 el.6ec,should any member of the public request dlaclosure at this Inlormation, I request that CIWMB <br /> contact me at the adreas anc :elephone number Sol <br /> I cerdly that undar penalty of perjury,under the laws or the Stets of California thel the Information provided above It true and correct.in add0 on,I am aware that latelicatlor of thle <br /> irform atlon may result Ir Civ,I pisnaltisoup to$25,000 per day,per vlo!alion or odminlafrative penalise up in 55,060 per v ation par day as dssaribed in Puolio PaouMes Code <br /> sectior 42962. <br /> 14 q <br /> ✓�f�Sl^ �j lc.l <br /> Representative Name(print) Rekidentaillyp4 Signature Date 32876 <br /> ttitt� Tn1I Fraa 1.ARR_RQR.nAnn / www_(,Iwmh.r:st.nov/Tirest/ <br /> f, 'd 0666 131783SH-1 JH WJ02 :Z T 9002 LO UeC <br />